Doctors are seen as somebodies. What separates them from healers is that healers bridge the gap between somebody and nobody by forming a partnership with patients based on equal dignity. I believe that affirmation of everyone's personhood is a healing interaction for patient and healer alike. –Dr. Jeffrey Ritterman, Kaiser Permanente

The Evolving Doctor-Patient Relationship

Rankism permeates all the professions, and health care is no exception.

Historically, medicine relied on the extreme difference in rank between physicians and patients to elicit trust, compliance, and hope during times of illness. But now, emboldened by knowledge gleaned from books, support groups, and the Internet, people are transforming themselves from docile patients into informed, engaged clients. Increasingly, patients come to the doctor's office with sophisticated questions and a desire to participate in decisions regarding their treatment. The era of the "MDeity" is passing into oblivion, and the traditional model of doctor-patient relationships is gradually being replaced with one of partnership. In light of this historic shift, it's no surprise that recent studies suggest that apologies from doctors significantly reduce the incidence of malpractice lawsuits.

Another example of patients' increasing desire to have a say in health matters is the hospice movement. By championing the idea of death with dignity, hospices have enabled people to retain as much responsibility for their end-of-life care as possible rather than surrender it wholesale to health care providers.

Rankism Among Health Professionals

In the larger fraternity of white coat providers, rankism manifests itself among practitioners holding different ranks. Doctors taking advantage of interns is a ubiquitous theme on hospital TV shows. Residents find themselves both recipients of and contributors to abusive situations, and nurses have legitimate complaints about their treatment by physicians.

Within the nursing order—nurse practitioners, registered nurses, licensed volunteer nurses, and medical assistants—rankism also rears its ugly head. All of this takes its toll not only on caregivers, but ultimately on patients as well.

Relationships between practitioners of different medical modalities and orientations—allopathic, naturopathic, and the various schools of complementary and alternative medicine—are also infected with rankism. Certainly, when it comes to treatment, there are legitimate questions concerning effectiveness. But methodological standards often are not applied evenhandedly to the practices and cures advocated by different traditions. And organizations representing these traditions vie mightily with each other like medieval guilds to foster and maintain the demand for their own services rather than focusing objectively on what works best for patients.

Not surprisingly, the rankism that infects health care arises in part from the way in which its professionals are educated. The seventy-two hour shift for interns is a legendary horror story in point. Like other initiation or hazing rites, such exploitation is dangerous—in this case it adversely affects the health of the interns and increases the chance of their making medical mistakes. In addition, these "ceremonies of degradation" perpetuate a rankist environment because they predispose young physicians to repeat the behavior once they've gained membership in the exclusive club that has been tormenting them. As the training of health care providers is stripped of traditional indignities, graduates will lose the desire to impose them on the next generation.

With the advent of managed care, doctors have also become increasingly vulnerable to bureaucratic rankism. In an email dated July 8, 2005, a high-level administrator in the Office of Inspector General of the U.S. Department of Health and Human Services reported on what he hears from physicians working in health maintenance organizations:

Doctors say they feel like nobodies because that's how the health care system treats them now. Many HMOs impose restrictions on how physicians provide patient care. For example, they are under pressure from management to see no fewer than a set number of patients each day, and limits are placed on how much time they can spend with each one. Doctors were trained to see themselves as healers, yet to a health administrator they are pieceworkers. However, recently the situation is beginning to change as a result of pressure from doctors and patients.

Another manifestation of rankism to which doctors are subjected is best understood as "reverse rankism." I've heard from a number of doctors that with the loss of their former godlike status, some patients try to turn the tables on them. Armed with a few tidbits they've picked up from the Internet, they attempt to pull rank on their doctors. A brief conversation clarifying the evolving doctor-patient relationship is usually all it takes to establish a healthier partnership.

The Health Benefits of Recognition

All these forms of rankism have counterparts within other hierarchical entities such as the academic, legal, and ecclesiastic professions, as well as business, the police, and the military. However, health care practitioners bear a double burden because they must deal not only with the rankism within their own hierarchy but also the casualties created by rankist abuse in all the others.

The rankism that pervades society is a serious threat to public health in much the same way that smoking is. This analogy can even be extended to "secondhand rankism"—namely, that resulting from passing a rankist insult along to someone of lower rank, sometimes referred to as the "kick-the-dog" phenomenon. The depredations to which the working poor are exposed take an unremarked toll that, over a lifetime, shows up as significantly enhanced morbidity and reduced life expectancy. A cover story in the New York Times Magazine makes the case that the ongoing stress experienced by those of low socioeconomic status in inner cities is a silent, unperceived killer.

In an email communication, Dr. Jeffrey Ritterman, who is chief cardiologist at the Kaiser Permanente HMO in Richmond, California, acknowledged this. Noting that his hospital serves a population of low socioeconomic status and great ethnic diversity, he observed: "Many of our patients suffer from nobody status, which deeply affects their health outcomes." That rankism is also a factor in determining who is afforded health care becomes especially clear in the aftermath of crises like Hurricane Katrina, which exhausted resources in New Orleans and along the Gulf Coast in 2005.

In ancient times, an excruciating form of execution was known as "death by a thousand cuts." Its modern counterpart is "death by a thousand indignities."As evidence of the adverse effects of rankism on public health mounts, health care professionals are going to feel honor bound to educate the public about the social costs of malrecognition.

To deal with this public health menace we are going to have to purge rankism from all our social institutions in the same way that, led by a series of Surgeons General, we are curtailing public smoking.

Given the cumulative damage wrought by indignity, we should expect to see benefits to those who manage to shield themselves from it. A study by Dr. Donald Redelmeier of the University of Toronto suggests exactly that. He reports that Oscar winners live on average almost four years longer than other actors. For multiple Oscar winners, it's six years. Dr. Redelmeier argues that such success has a powerful influence on a person's health and longevity. He says, "Once you've got that statuette on your mantel, it's an uncontested sign of peer approval that nobody can take away from you. [Winning an Oscar] leaves you more resilient. Harsh reviews don't quite get under your skin. The normal stresses and strains of everyday life don't drag you down."

Dr. Nancy Adler, director of the Center for Health and Community and professor of medical psychology at the University of California at San Francisco, says:

Status is made up of many things—it's a matter of education, money, ethnicity, and gender. What we're learning is that in each of those areas, health is better the higher up you are.

The issue for stress is not how many demands you have, but your sense that they are manageable. A demand that you have the resources to deal with—that you have some control over—can actually be invigorating. It's the difference between a challenge and a threat. Control goes up at each step up the social ladder and that usually works to diminish stress.

Dr. Adler quotes Leonard Syme of the University of California's School of Public Health: "If you could only ask one question of a person, and you wanted to be able to predict what their state of health would be, it would be their social class." Syme showed that it wasn't just that those of the highest status had a longer life span and better overall health than those at the bottom, but that health improved with each rung up the social hierarchy. It is important to recognize that higher social class doesn't just mean better health care. It also often means less exposure to rankism, which in turn means less need for health care.

In this vein, Michael Marmot, a professor of epidemiology and public health at University College London and author of The Status Syndrome: How Social Standing Affects Our Health and Longevity, writes:

The higher your status in the social hierarchy the better your health and the longer you live…A way to understand the link between status and health is to think of three fundamental human needs: health, autonomy, and opportunity for full social participation…The lower the social status, the less autonomy and the less social participation.

Participation includes the positive feedback one receives from social recognition and being a valued member of society.

Dignity: A Centerpiece of Health Care

This brief survey of the effects of rankism on health and the health care system suggests that any system-wide fix will need to make dignity its centerpiece. To be successful today, a health care model must proffer respect for patients, who are rebelling against their traditional infantilization; it must preserve the dignity of doctors and nurses, most of whom have chosen the profession out of a desire to serve; and finally, it must respect the indispensable role of administrators, who have the thankless task of managing a scarce but desperately needed resource.

Quite obviously, no society can regard itself as dignitarian if access to quality health care is limited to those with enough money to afford it.

Equally obvious is that health care, like any resource, is limited in supply and must be rationed some way or other. Controlling access to it by the ability to pay might be justified when a resource is optional, but not when it is indispensable to life, liberty, and the pursuit of happiness.

Clearly health care falls into that category, and accordingly, a dignitarian society will see to it that everyone can readily obtain both routine and specialized evaluation and treatment in the mode of their choice. The organization Search for Common Ground has put together a project involving leading national stakeholders reflecting a broad spectrum of interests and perspectives. Its goal is to identify consensus-based recommendations to provide health care coverage to "as many people as possible as quickly as possible." The idea is to develop widely supportable proposals among these "strange bedfellows" in the hope of breaking a decades-old gridlock on how to extend coverage to the uninsured.

In conclusion, here is an example that illustrates both the bureaucratic obstacles to building a dignitarian health care system, and what a determined government official can do to offset the dependence of health on social status. In 1995, Thomas A. Purvis, an evaluator in the office of the Inspector General in the U.S. Department of Health and Human Services, became aware that only a small fraction of youth covered by Medicaid were actually making use of the dental services for which they were eligible. He conducted a study to find out why. His principal findings were:

Bureaucratic red tape and inadequate reimbursement were factors in why dentists did not seek business from low-income families. But these were not the only reasons.

Dentists were turning down young Medicaid patients and their families because they viewed them in a way that smacked of rankism. The dentists tended to stereotype all such patients as being uninformed about the importance of good dental care, disruptive in the waiting room, unreliable about keeping appointments, and disinclined to follow their recommendations regarding home care between visits.

As a result of Purvis's analysis, state and federal agencies began working together to disabuse the dental profession of its perception of Medicaid patients. In combination with raising the fees paid to dentists, this strategy resulted in a significant elevation in the percentage of children from low-income families served by the Medicaid-funded dental program.

This story suggests that positive intervention by a service-oriented bureaucracy can offset the impact of rankism on health. But an October 2005 article in the New York Times indicates that, while some progress has been made, the same social status factors that were identified by Purvis ten years ago continue to limit the numbers of those eligible for Medicaid who are actually served by the program.

Today, rankist barriers in health care are like the racist barriers in public accommodations that existed before the nation enacted the civil rights legislation of the 1960s. Until these barriers are removed, they will continue to do serious disservice to a large group of citizens.

This is the eleventh part of the serialization of All Rise: Somebodies, Nobodies, and the Politics of Dignity (Berrett-Koehler, 2006). The ideas in this book are further developed in my recent novel The Rowan Tree.